Brachiobasilic versus brachiocephalic arteriovenous fistula: a prospective randomized study.
BACKGROUND
The most recent Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines recommend that the order of preference for arteriovenous fistula (AVF) placement is the radial-cephalic primary AVF, followed by the secondary brachiocephalic (BC) and, if either of these is not viable, then brachiobasilic (BB) AVF should be fashioned. However, there is limited prospective data comparing technical and clinical outcomes of these two approaches. The purpose of our study was to compare outcome, patency, and complication rates in these two autogenous upper arm AV accesses.


METHODS
Between December 2003 and and January 2007, patients (61 male, 39 female) who have lost more distal AVFs were enrolled in the study. After preoperative duplex mapping, patients with patent both basilic and cephalic veins greater than 3 mm of diameter were randomized into BCAVF and BBAVF groups, each group consisting of 50 patients. All procedures were performed under local anesthesia as one-stage procedures. Follow-up data were prospectively collected. Kaplan-Meier analysis was used to calculate primary and secondary patency rates. Univariate and multivariate Cox-regression analysis was used to find risks for the occurrence of thrombosis.


RESULTS
Baseline demographics, clinical characteristics, and preoperative history dialysis access were comparable between groups with the exception of the fact that mean caliber of the basilic veins were larger (4.51 +/- 0.93 mm vs 3.90 +/- 0.1 mm; P = .002). The mean duration of operation was significantly shorter in the BC group compared with the BB group (P < .001). There was no significant difference in the thirty day mortality, wound complications, 24 hour thrombosis, postoperative hemorrhage, maturation, and time to maturation between the groups. Mean follow-up was 43.2 +/- 1.8 months. Primary patency at 1 and 3 years of follow-up was 87% and 81% for the BC group and 86% and 73% for the BB group (P = .7) Secondary patency at one and three year follow-up was 87% and 70% for the BC group and 88% and 71% for the BB group, respectively (P = .8). Twenty-eight patients (28%) in the BC (18 patients) and BB (10 patients) group died with a patent fistula during the follow-up period (P = .18). Multivariate analysis revealed that use of dominant arm increased the risk of fistula failure.


CONCLUSIONS
We conclude that brachiobasilic and brachiocephalic AVF are equally effective alternatives; however, a longer and demanding operation with BB AVF construction should be considered.
Koksoy
Cuneyt
C
Department of Surgery, Ankara University, Ankara, Turkey. cuneytkoksoy@hotmail.com
Demirci
Rojbin Karakoyun
RK
Balci
Deniz
D
Solak
Tuba
T
Köse
S Kenan
SK
D001132:Arm / Q000098:blood supply*; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects; D001916:Brachial Artery / Q000503:physiopathology / Q000601:surgery*; D016121:Brachiocephalic Veins / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D006435:Renal Dialysis; D018570:Risk Assessment; D013927:Thrombosis / Q000209:etiology; D013997:Time Factors; D017211:Treatment Failure; D016896:Treatment Outcome; D014654:Vascular Patency